I welcome the Minister for Health and Children to the House.
Nursing in Ireland: Statements.
I am grateful to Seanad Éireann for giving me this opportunity to make a comprehensive statement on nursing. This is the first opportunity I have had to do so following my appointment as Minister for Health and Children.
The first topic I wish to address is the nursing shortage. It is generally overlooked that the number of nurses on the active register of An Bord Altranais is at an all time high at 50,544. Between 1990 and 1998, the number of whole-time equivalent nursing staff employed in the public health service increased by 8%. The end of 1998 figure of 26,695 whole-time equivalents represents over 31,000 individuals due to the very significant numbers who have opted to work in job sharing or part-time arrangements. In addition, significant resources have been invested to facilitate general practitioners in employing practice nurses in their surgeries. There are now several hundred nurses working in this area.
While the number of qualified nursing staff in employment is now at an all time high, the transition from the traditional apprenticeship model of nurse education to the diploma-based programme has impacted on the availability of nurses. The service contribution of students trained under the traditional model has been replaced by a skill mix of registered nurses and non-nursing personnel. Ultimately, the service contribution of the apprentice students will be replaced by some 1,525 staff nurses and 662 non-nursing personnel. About 1,460 replacement staff nurse posts and 630 non-nursing posts have been approved to date. While this has enhanced the quality of nursing care through the creation of additional nursing posts in hospitals, it has had the effect of absorbing the pool of surplus nurses that existed when student nurses were part of the rostered workforce.
It should be noted that in 1993-4 when the first diploma-based programme was being planned, there was increasing resistance from the nursing profession to maintaining a high student intake at a time when nurses on registration were finding it difficult to find employment. This issue was highlighted by An Bord Altranais in 1994 in a report which referred to a general contraction in nurse employment both at home and abroad. In 1990 the Department commissioned a study of nursing personnel which was presented to the Department in 1995. This report recommended a gradual reduction in the number of student nurses up to the year 2000.
It is ironic that there is now a general shortage of nurses not only in Ireland but in the United States, Britain and most other European countries. Against this background, it is encouraging that there has been a net inflow of nurses to Ireland in recent years. Data maintained by An Bord Altranais show that in 1996, the inflow was 939 nurses while the outflow was 1,079 nurses. By 1998, however, the number coming in had increased to 1,400 while the number leaving had decreased to 850. Provisional inflow figures for 1999 of 3,171 represent a dramatic increase over 1998. This trend proves that Ireland continues to be competitive when it comes to recruiting nurses from abroad.
My Department is in discussion with the relevant Departments and with An Bord Altranais regarding entry visas/work permits for nurses recruited from outside the European Union or European Economic Area. These discussions are aimed at ensuring that there are no unnecessary barriers to entry.
The most recent survey of nursing vacancies, carried out by the Health Service Employers Agency related to the position at the end of September 1999 and found that there were 1,180 staff nurse vacancies in gross terms. This was the most comprehensive report to date and covered all agencies and nursing disciplines. The net figure when adjustments are made for the utilisation of agency nurses and overtime working was 428.16.
The results confirmed again that there is not a nationwide problem regarding the availability of nurses and that difficulties largely relate to the greater Dublin area. While some nurses have always moved from Dublin to other parts of the country, investment in hospitals and the development of regional specialties in recent years have increased demand for nurses outside the Dublin area. Within Dublin, issues such as housing costs, traffic problems and lack of car parking facilities have been cited as disincentives to the recruitment and retention of nurses. However, these issues are not unique to nurses or to the health service.
Nurse recruitment is carried out on an ongoing basis in most hospitals and the level of vacancies fluctuates accordingly. At any given time, significant numbers of nurses would be in the process of being appointed by employers or moving from one employment to another.
It is also worth noting that OECD health data for 1998 show that Ireland is significantly out of line with other European countries in relation to the very high ratio of nurses per hospital bed employed here. We have 1.26 nurses per bed while France has 0.42.
I would now like to refer to initiatives aimed at attracting applicants to study nursing. My predecessor, the Minister for Foreign Affairs, Deputy Cowen, increased the number of nurse training places by 153 between 1998 and 1999. This was the first increase in places since the diploma programme was introduced in 1994. Some 3,100 student nurses are in training at present. The 2000 intake will be 1,500, an increase of 300 over 1999. This increased figure was agreed with the Nursing Alliance as part of the settlement of the recent nurses' strike. A further 20 places are available on a new direct entry midwifery programme which will be introduced on a pilot basis next June.
In 1999, following a local and national recruitment campaign costing £400,000 and funded by the Department, the number of applicants increased by over 40% over 1998. This resulted in the largest number of direct entrants to nursing for several years. A total of 1,215 training places were filled in 1999, including record intakes of students to psychiatric and mental handicap nurse training.
Other measures which have been taken include the annual maintenance grant for nursing students – which is not subject to a means test – which has been increased from £2,500 to £3,250, almost double that which the average student receives in third level education, and that is a factor which should be borne in mind when we compare like with like. The rate will increase again to £3,325 with effect from 1 April 2000. In addition, allowances for external clinical placements, books and uniforms are also being increased. The range of leaving certificate subjects that may be presented by an applicant for admission to the nursing diploma programme has been expanded. The requirement to have a foreign language in the leaving certificate has been removed.
While the recruitment of nurses is primarily a matter for individual employers, who take their own initiatives in this regard, a range of initiatives have been taken or are being progressed with a view to stabilising the situation and, where possible, improving it. These initiatives include the following: arrangements have been agreed with the nursing unions to allow more favourable assimilation arrangements on to pay scales for nurses taking up both permanent and temporary appointments; a significantly improved regime of allowances in respect of nurses working in specialised areas such as operating theatres and intensive care units has been introduced; discussions with the nursing unions are continuing in relation to the introduction of more flexible working arrangements for nursing staff; standardised overtime working arrangements have been introduced following agreement with the nursing unions; health service employers have been asked to examine the possibilities in relation to the introduction of term time working as an option for staff with family commitments; and the availability of return to work courses for qualified nurses who have been out of the workforce is being reviewed with a view to maximising uptake.
Another initiative is that my Department is engaged in discussions with health agencies in relation to the provision of specialist nursing courses at centres outside Dublin. As a result, ten students commenced a one year higher diploma in specialist nursing in Letterkenny General Hospital in January 2000 and six students commenced a higher diploma in nursing, critical care, in University College Hospital Galway, and a further course is planned for Waterford Regional Hospital. In addition an anti-bullying policy has been prepared and agreed with the nursing unions and was published in December 1999.
The promotional structure in nursing, including the introduction of a clinical career pathway, is being significantly improved on foot of the recommendations of the Commission on Nursing. A study of the nursing and midwifery resource by the nursing policy division of the Department of Health and Children commenced in 1998 with the primary purpose of forecasting future nursing and midwifery resource needs. Following on from this, a national study on turnover in nursing and midwifery has been commissioned by the Department through the Health Research Board and awarded to the department of nursing studies, NUI, Cork.
The Commission on Nursing recommended that the Department of Health and Children, health service providers and nursing organisations examine the development of appropriate systems to determine nursing staff levels. The need to address skill mix issues was also highlighted in the report of the Commission on Nursing. These recommendations are included in the priority action plan agreed with the Nursing Alliance as part of the settlement of the nurses' strike. It has been agreed that these issues will be addressed by a joint committee representative of nursing unions and health service employers. This committee is in the process of being established.
These initiatives represent a very significant effort by my Department to improve the situation. In the longer term, it is hoped that the substantial increase in the number of student places will provide enough registered nurses to fill all vacancies.
I avail of the opportunity presented by this morning's proceedings to bring Senators up to date on what has been achieved to date in relation to the implementation of the report of the Commission on Nursing since nursing issues were last debated in this House around the time of the first ever nurses' strike last October. My predecessor, the Minister, Deputy Cowen, predicted correctly at the time that the commission's report would feature in the settlement of the strike.
Now that the long running nurses' pay dispute has finally been resolved, my absolute priority in the nursing area is to press ahead with the agenda for change recommended by the Commission on Nursing. This will be done in partnership with the key stakeholders involved, including the nursing unions.
The commission has set out a comprehensive framework for addressing the real underlying problems in nursing and midwifery. Its wide-ranging recommendations take full account of the realities within which nursing must be sustained and developed as a key profession in the health services. The implementation of the fundamental structural reforms advocated by the commission will transform the way in which the nursing profession is regulated, educated and developed. Exciting new clinical career pathways will be introduced and nurses and midwives will be provided with enhanced opportunities for professional development.
As part of the settlement of the nurses' dispute, agreement was reached between my Department and the nursing unions on an action plan setting out the objectives to be achieved over the next two years in implementing certain core recommendations of the Commission on Nursing. The Government, for its part, has provided £10 million for initiatives to be undertaken this year under the agreed action plan.
Since the action plan was agreed last November considerable progress has been made to date in implementing its provisions. A monitoring committee has been established to review progress on a quarterly basis on the implementation of the Commission on Nursing report. This committee is composed of representatives of my Department, health service employers, the nursing unions and An Bord Altranais. This partnership approach, which was proposed by the commission, will facilitate constructive engagement between the key stakeholders in progressing the huge agenda for change recommended by the commission.
The National Council for the Professional Development of Nursing and Midwifery has also been established. This new independent statutory body has responsibility for the development of a new clinical career pathway for nurses and midwives, involving the creation of clinical specialist and advanced practitioner posts.
In response to the nursing shortage, the action plan, as I previously indicated, provides for an increase of 300 additional training places this year on the nursing registration-diploma programmes. The intention is that a total of 1,500 training places will be available – 1,000 in general nursing, 300 in psychiatric nursing and 200 in mental handicap nursing.
I would like to refer to three important new developments that form a central plank of my Department's strategy for ensuring that the additional training places are provided. A new integrated school of general and psychiatric nursing is being developed by the Western Health Board at Castlebar General Hospital - St. Mary's Hospital with an annual intake of 50 nursing students. This new school will be linked to the Galway-Mayo Institute of Technology.
The school of general nursing at Tralee General Hospital operated by the Southern Health Board is being redesignated as a pre-registration nursing education school. It will have an annual intake of 45 students and will be linked to the Institute of Technology in Tralee. Some of the students assigned to the school in Tralee will undertake their clinical placements at Bantry General Hospital.
The North Eastern Health Board regional school of psychiatric nursing is also being reactivated. This school, which will be located at St. Brigid's Hospital, Ardee and St. Davnet's Hospital, Monaghan will have an annual intake of 25 students. The third level educational partner will be Dundalk Institute of Technology.
My Department is currently engaged in negotiations with a number of existing schools of nursing with the specific objective of securing additional training places at those schools. I am confident there will be a successful outcome to these negotiations and that the target of 300 extra places will be achieved across the three pre-registration nursing disciplines.
I have referred to the success of last year's recruitment drive, which resulted in the filling of the largest ever number of places on the nursing diploma programmes. In view of the success of that campaign, further funding totalling some £400,000 was made available to the various schools of nursing throughout the country late last year to enable them to undertake local marketing campaigns in their catchment areas aimed at promoting nursing as a career. I understand from the Nursing Careers Centre that it has received more than 5,000 applications for nurse training this year. This means that there are more than three applicants for every available training place. This is very encouraging, bearing in mind that the overall number of places is being increased by 25% over last year and the downward trend generally in the volume of applications for positions in the public service. It is an important point that 5,000 people are applying for 1,500 places.
A new direct entry midwifery education programme will be introduced on a pilot basis next June. This three year programme will be operated by Trinity College in association with the Rotunda Hospital, Dublin and Our Lady of Lourdes Hospital, Drogheda. A total of 20 training places will be available on the programme, which is open to school leavers and mature persons. Funding has been provided to the maternity hospitals to facilitate a doubling of the theoretical component of the current two year post-registration midwifery education programme from 13 to 26 weeks. Such an increase has long been sought by midwifery interest groups.
A working group has been established to undertake a review of the content, duration and academic award of the current 18 month post-registration sick children's course. Ongoing funding has been allocated among the health boards for the provision of new technology and, where appropriate, clerical support for public health nurses.
The important new initiatives that I have outlined illustrate how real progress can be achieved in a relatively short space of time in tackling the agenda for change recommended by the Commission on Nursing. I have no doubt that this has been possible because of the improved industrial relations climate that now exists following the settlement of the outstanding pay issues. For the first time in perhaps several years we have a unique opportunity to focus our collective energies constructively and in a spirit of true partnership on bringing about the changes that we all agree are desirable and necessary. The Commission on Nursing provided us with a secure basis on which to further develop nursing and midwifery in order to enable the profession to respond successfully to the challenges arising from changes in the organisation and delivery of our health services. Let us all grasp this opportunity and work together to achieve the objectives set for us by the commission.
For my part, I am fully committed to the full implementation of the commission's recommendations. While all the recommendations are important, it is accepted that they cannot all be implemented at once. The action plan agreed with the nursing unions represents an important phase of a structured programme for the implementation of the commission's recommendations on an incremental basis over a period of time. I shall be taking a particular interest in the steps being taken to achieve all the objectives set out in the action plan between now and the end of next year. It is my firm intention that further action plans will be prepared in close consultation with the key stakeholders to provide for the implementation of the remaining recommendations over future years.
I thank Senators for giving me the opportunity to make a detailed and comprehensive statement on nursing matters. The nursing service is a vital resource and I am determined to ensure it is nurtured and developed in accordance with the vision of the Commission on Nursing. I am convinced that the full implementation of the commission's recommendations will bring about the structural and other reforms necessary to facilitiate the ongoing development of the nursing profession. I assure the house that I will work assiduously during my term of office to advance this objective in close partnership with the nursing unions and the other key players.
A report in the Irish Independent of 18 February 2000 conflicts with the points the Minister has made. The headline reads: “Nurse shortage spreads across country”. The newspaper article quotes the general secretary of the Irish Nurses Organisation, Mr. Liam Doran, as saying that the shortage has spread beyond Dublin. Up to now the Minister has admitted that there is a shortage of nurses in the greater Dublin area. Mr. Doran says, however, that there is an acute lack of nurses in Dublin's major hospitals, which has doubled to 1,100 since last June. The INO general secretary also refers to serious problems, including the retention of nurses, poor rates of pay, and housing and transport costs. According to Mr. Doran, a newly qualified nurse is still earning just £15,606 a year. I cannot contradict the specific facts provided by the general secretary of the Irish Nurses Organisation. The Minister mentioned the recruitment of nurses from abroad, but Mr. Doran is quoted in the Irish Independent article as saying, “Although hospitals have engaged in intensive recruitment campaigns abroad, including the Philippines, they have not been able to entice nurses to come to Ireland in sufficient numbers.”
Mr. Doran refers to hospitals changing their policies and offering flexible working hours. I am glad to see that job sharing, which until recently was not considered a very attractive option within hospitals, is now being offered to nurses and is being taken up readily. There is a problem, however, because it appears that job sharing links in with agency nursing. There are concerns, particularly in psychiatric hospitals, that the nurse-patient relationship might be hampered by a staggered approach to staffing. Such chopping and changing of personnel may not provide the best quality of care, particularly in psychiatric hospitals.
Mr. Doran referred to a survey carried out last November showing that more hospitals in Dublin are using agency nurses and care assistants to fill the gaps. Yesterday, in my contribution to the debate on hospital waiting lists, I referred to the big influx of agency nurses. I provided a statistic from the Mater Hospital which is spending £2 million on agency nursing in contrast to St. James's where they allow overtime. An integrated strategy is required to ensure a measure of conformity. I find it extraordinary that two Dublin hospitals should have different ways of dealing with the nursing shortage – one through overtime and the other using agency nurses.
There is nothing surprising about that.
I am sure that money is being ploughed in, but maybe there are better ways of dealing with structures. There is a need for interdisciplinary approaches. I would need a few hours to go through all the facts and figures contained in the Minister's presentation. It is very hard to digest them instantly. I can question them, however, and will come back to discuss them at a later stage. The document from the HSEA provides a figure for reported nursing vacancies of 1,180.46, which the Minister also mentioned.
Last April, the Oireachtas Committee on Health and Children was presented with other documents from An Bord Altranais, the HSEA and the INO. The latter group's figures do not conform with those from the HSEA. I would like to go through those figures to see if we can come up with some basic facts so that we can have a concrete understanding of the exact number of nursing vacancies. We understand the shortages in the greater Dublin area. The Minister himself referred to traffic problems and the high cost of housing as reasons for the shortage. He also said that more nurses were being taken on down the country and therefore they did not have to go to Dublin to find work. Let us tease out the situation.
The INO submission in April 1999 provided the historical perspective on the current situation. Cuts in student nurses' pay in 1987 and demographic and educational changes have created the decline in numbers. Fewer school leavers have been entering the nursing profession and there is only one annual intake of student nurses.
Recently I attended a graduation ceremony for 49 nursing diploma students at the University of Limerick. Of that number, only ten were staying in the nursing profession. I find that extraordinary considering they had taken up nursing after their leaving certificate as an entry to third level education. The biggest percentage of them was going to Mary Immaculate teacher training college. Others were taking well remunerated jobs as representatives for medical equipment companies. The remainder were going to work abroad, but not in nursing jobs. I find that extraordinary, because they were a very strong, healthy and lovely crop of girls. There was not a man among them, of course, which I wonder about. There is no reference anywhere in the document to that.
True. I would never use the word "crop" in that context. I would be slaughtered.
A second species.
I suppose the appropriate collective noun is a group of nurses. In all the discussions about nursing shortages, there has been no mention of getting men into the profession, even though we are always seeking gender equity. I am in favour of positive action to achieve that. It would be illegal for advertisements for nursing staff to specify female recruits, but is any effort being made by career guidance teachers in boys' schools to push nursing as a career? Why are they not coming through? It is probably because the pay rates would not be very attractive to them. I am not saying that men do not work as hard in their chosen professions – of course they do – but they certainly seem to feel that nursing is very difficult. Men would be physically well equipped for all the pulling and dragging that has to be done by nurses, but they do not seem to want jobs in that sector.
Brighter prospects and better remuneration packages in the UK were also cited in the INO's submission as reasons for the nursing shortage here. Other reasons included the continuous improvement in other educational and career areas, as well as a reduction in the number of places available for student nurses each year. For instance, in 1998, of the 1,596 places available only 1,095 were taken up. All this information is known to second level students who are anxious to pursue nursing as a career. There was never as much interest in investigating careers as there is now. There are career guidance conferences everywhere and youngsters know where they are going. They will compare jobs and they realise that in teaching they will be finished work at 3 o'clock or 3.30 p.m. They hear people saying the perception of nursing is that it is extremely hard. The statistics for 1998 from the INO report confirm that for the first time none of the areas of nursing filled their available places. The reasons for nurses leaving the profession, especially in larger urban areas, include the cost of living, reduced living and travel costs in other areas, and more attractive private sector employment.
More nurses are opting for part-time work and that is acceptable if that is what they want, particularly in job-sharing. According to the INO, the reasons nursing is no longer regarded as an attractive profession include the fact that it is poorly paid – this is the case, despite improvements following the nurses' strike – and is perceived as involving unsocial hours. That is a fact and it has not changed. It is also perceived as having a long working week and a low level of annual leave – that is a fact also – and it is a stressful occupation. There is no doubt about that.
The Minister referred to an anti-bullying programme but apart from that nursing is a highly stressful occupation. Increased waiting lists and ward closures are taking their toll on nurses who are at the coalface. They also have to listen to patients who may not be at their best if they are sick, sore and sorry for themselves in a hospital bed. One can understand why people in a depressed and stressed state might complain, but doctors do not tend to be on the receiving end of patients' negative comments whereas nurses do. Despite this, nurses take it very well and are extremely patient.
The INO also states that there are minimal promotional opportunities in nursing which is still viewed as an old-fashioned, hierarchical and female profession compared to newer careers. We must examine all these facts.
The Minister should clarify the reason third level fees cannot be waived. He said last night that there was a reason for this and I hope he will address it. The very active student nurses from NUIG were on "Morning Ireland" recently and said they were not prepared to accept it. They are in third level.
Is that the post-diploma year?
Yes. They feel they are second class undergraduates.
There is a story to that.
There may be, but that story is not getting across in the media. I do not know if the story is good or bad, but I hope it has a happy ending.
Stories do not always come across with clarity in the media.
The issue will not go away.
I accept that.
It has to be addressed. It is not as if there are millions of people seeking to take on a post-diploma year. Anyone who stays on for that year, given the fallout at diploma year, should be affirmed by having their fees waived. It is very costly for them and their parents.
I have more interesting statistics from a study done by UCC's Department of Nursing Studies in June 1999 on student nurse characteristics, biographical information, motivation and attitudes to nursing as a career. Perhaps the Minister has read it. One learns a lot from it and I do not have time to go into all its recommendations, but the post-diploma issue must be looked at quickly. The report seeks the development of nursing education centres in all training hospitals and the creation of a clinically based career path for them, which the Minister referred to, as well as the National Council for the Professional Development of Nursing and Midwifery, which he also addressed.
I will not go through the HSEA recommendations because we have this recent document, but An Bord Altranais has different figures and facts. We have three organisations here and it is not that they are not all singing from the same hymn sheet – I would not expect them to – but their figures and suggestions are different. I do not understand this. An Bord Altranais is encouraging registered nurses to come off the inactive file and return to work. I would love to know if statistics show that is happening. It also wants an increase in the number of training places available – there has been an increase, as the Minister said – and increased promotional campaigns. Did the Minister mention a figure of £400,000 or £40,000 for the last campaign?
It is £400,000.
That is what I thought. I confess I did not see much of that advertising. Was it on radio or television? Where was the advertising? If I did not see it, though I am interested in health, I wonder where it was. Was it in second level schools?
Yes.
I feel it should be in the national press.
We are trying promotion in the schools.
I know that, but at the same time people read newspapers and watch television. If the advertisements were very good they would have far more impact. One takes what one is given in school with a grain of salt. Everyone knows that. Career information is hurled at students at a very stressful time while preparing for an examination and filling out a CAO form.
One must ask where teenagers come together. I have seen very attractive advertising, particularly in Canada, to encourage people to take up nursing. One must have the advertisements where people are – bus stops, television or radio – and they must be shown during the programmes people watch. Attractive advertising would get far more applicants, though I am not saying that promotion in second level schools should not be done. Modern advertising would be excellent. Leaflets should be distributed to youth clubs and other areas where students gather. They could pick them up when they are together and say, "Let's think about nursing."
Another recommendation from An Bord Altranais which ties in with the UCC report relates to the reasons young people choose nursing as a career. One reason is to help those in need. One is talking about a group of young people at an aspirational stage of their lives when they are full of altruism. When pupils from Laurel Hill were here, some of whom want to become politicians, I asked them about nursing, but we did not have time for them to respond. They are very idealistic at that point. Another reason given was that they wanted to deal with people rather than things, which is very interesting, and a third reason was job mobility and a chance to travel. There is no doubt one gets that chance. How many of our young people go to Australia or America? Sadly they do not return. It is not sad for them, because obviously they have a good quality of life, but it is sad for us because we lose them.
Previous experience working in health care was the most important influencing factor. I stress that because young people who attend my clinics ask if they can be exposed to the health service, which can be done through the social side of transition year. They can work for the Society of St. Vincent de Paul or, in Limerick, for the Bawnmore facility for those with mental disability. We should give them more opportunities in their summer, Christmas or Easter holidays to gain that exposure, be it in nursing homes, community nursing or public health nursing. I would like an increase in the numbers of public health nurses, as that is where they are reaching out to people in need, particularly the elderly.
There seems to be a shortage of nurses nationwide, but particularly in the Dublin area. The three bodies I referred to agree that education and pay are problem areas and more nurses are needed. Nurses need flexible career options, clinical based career paths, increased training places and more attractive remuneration packages. Those are recommendations from people at the coalface.
I hear through the grapevine that the Minister is to prioritise the human element of the health service, which will relate to reducing waiting lists and increasing nursing training places. He did not get a chance last night to respond to the suggested link between increased waiting lists and the nurses' dispute. I would have liked the Minister to expand on that, as he said the newspapers misrepresented him. Waiting lists and attracting people to nursing are linked. I ask the Minister to address this and to elevate nursing.
The jury is out as to whether the word "vocation" should be used about nursing. Some nurses say they are sick of the Florence Nightingale image of vocation. They do not want that any more and want to move into the new millennium as part of a respected profession. On the other hand, the basis of nursing is vocational, as it is an extraordinarily difficult profession. One meets people at their lowest ebb and one needs to be physically fit for the long hours and stress associated with nursing. There should be appropriate pay for that. I have seen advertisements inviting people of 20 or 21 from overseas to take up jobs here paying £30,000. When computer gurus are being attracted by massive salaries, people ask why they should go into nursing since their post-primary qualifications enable them to take any option from the CAO. There is massive recruitment to the hi-tech industry because of skill shortages and those who would have opted for nursing are taking that route. We are at crisis point.
Why is there such disparity between the various documents presented by An Bord Altranais, the HSEA, the INO and so on? If everyone works together, I am sure a practical figure can be arrived at.
I thank the Minister who I am sure will be back here again because this matter needs to be reviewed. We will be tabling a Private Members' motion or taking statements in the future on the issues raised today.
Nurses are a very important part of the health service. This is probably an understatement because the most eminent doctors and consultants spend relatively little time with their patients as a result of the nature of their work, except in the case of operations which can go on for some hours. Nurses are at the coalface of delivering the health service, particularly in the hospital setting. Senator Jackman referred to the Minister's speech which would take a number of hours to go through. There is a lot in it, including a lot of good news. I will touch on this, as will other Members on the Government side.
In recent years there have been difficulties which I will identify. Reference has been made to the difficulties in Dublin in recruiting nurses. These include traffic problems, the cost of housing and other related problems. There is also a difficulty in the smaller hospitals in attracting nurses, particularly small cottage hospitals in rural areas. I know of two hospitals where a list of successful candidates was compiled to go on a panel. However, as the panel was visited by the administrator or the nurse manager, the people concerned had obtained other jobs. In other words, people apply to particular hospitals but go elsewhere when the opportunity for work arises. One hospital advertised for nurses between six and seven times in two years and failed to get the required number. Each time the panel was filled but when the applicants were called they failed to take up the posts. Another small rural hospital advertised for SRNs and it received no application. Many of these difficulties are being addressed in a number of ways to which the Minister referred. Overtime is a short-term solution which I do not believe will solve the problem.
There is a degree of success, particularly in the mental handicap services. I refer to my health board area which has been successful in attracting female nurses who got married and have come back into the service. That is to be welcomed because in most cases they are mothers, and being mothers they are caring people, although I am not saying they were not caring people before they became mothers. These people, who receive refresher courses, provide a pivotal service. In another rural area a panel of nine people was compiled. In two months, three people on the panel refused employment. There must be some incentive to deal with this problem and I believe we have turned that corner.
Senator Jackman mentioned a report in a national newspaper about shortages spreading. The measures taken by the previous and current Ministers will take us out of this situation. I worked in the nursing service for a number of years. One of the reasons I did so was that I had a hero image of a local individual. This is also one of the reasons others have entered the nursing profession.
The College of Nursing in Tullamore is currently training approximately 20 students, one of whom is a male. It would be incorrect to say that males are not being recruited. What is important in recruiting nurses is to employ the best people, irrespective of gender. One is talking about the best people and this is what the health agencies are trying to do. It does not matter whether these people wear a skirt or trousers, what is necessary is to attract the best people. The College of Nursing in Tullamore, which is linked to the Athlone Institute of Technology, is 20 miles away from where I live and is in the centre of the region. This is a step in the right direction, because local men and women will be employed there and leaving certificate students will identify with these people working in local hospitals and decide they would like to be a nurse just as "Joe Bloggs" or "Cathy Barry".
Local training colleges are the answer to the problem because nowadays local people do not know the staff who work in their local hospitals. I do not know the staff who work in my local hospital because they are not locals. I am not saying these people should not be given jobs, but there is an identification problem on a local basis with these people. In the past it has proved an attraction to young people who can identify with local people in these jobs, and this is important. There is a College of Nursing in Castlebar which will be linked to the Galway/Mayo Institute of Technology. The training facility in Tralee has been redesignated as a pre-registration facility. This is one of the components which will attract young people to the profession.
The Minister referred to a number of extremely important issues. The College of Nursing in Tullamore began with an intake of 20 students. This increased to 30 students in 1999 and this year it will have an intake of 40 students. This indicates that we have turned the corner. In the psychiatric discipline, where there was tremendous difficulty in recruiting students, last year there was an all time high intake of approximately 200 students.
It is not true to say that we are not winning the battle – we are. The Government is not saying there are no difficulties but it is implementing measures to tackle the problems. The measures being taken are extremely important because the numbers applying for nursing posts indicate that we are being successful. My colleague, Senator Ormonde, is a career guidance teacher. These people have a pivotal role in directing young people into the nursing profession.
The Minister stated that settlement of the nurses' dispute was reached between the Department and the nursing unions based on an action plan setting out the objectives to be achieved over the next two years in implementing certain core recommendations of the Commission on Nursing. The Government has provided £10 million for initiatives to be undertaken this year under the agreed action plan. Since the action plan was agreed last November, considerable progress has been made in implementing it. I believe the monitoring committee was an extremely clever move because it has brought together all the strands of people involved in delivering the nursing services. The committee is composed of representatives of the Department of Health and Children, the health services employers, the nursing unions and An Bord Altranais. This partnership approach, which was proposed by the commission itself, will facilitate the constructive engagement between all the key stakeholders in progressing the huge agenda for change recommended by the commission. This could not be a better arrangement because everybody's point of view is considered. If the nursing unions were not involved, all hell would break loose. That has been avoided and this facility will deliver because this is a marvellous formula.
The National Council for the Professional Development of Nursing and Midwifery has also been established and this new independent statutory body has responsibility for the development of a new clinical career pathway for nurses and midwives involved in the creation of clinical, specialist and advanced practitioner courses. This is another step in the right direction. As the Minister said, the action plan provides for an increase of 300 additional training places this year on the nursing registration/diploma programme. This is a major step in the right direction. A total of 1,500 training places will be available – 1,000 in general nursing, 300 in psychiatric nursing and 200 in mental handicap nursing. A large number of males are involved in the latter two disciplines, psychiatric nursing and mental handicap nursing. These are the facts. There is a growing interest among male nurses in the general nursing profession and the paediatric discipline. The gender balance is being struck more evenly than is popularly known.
A new integrated school of general and psychiatric nursing has, as I have already stated, been opened by the Western Health Board at Castlebar General Hospital/St. Mary's Hospital with an intake of 50 students. It is linked to the Galway Mayo Institute of Technology. The Minister has provided £400,000 to the various schools of nursing countrywide to enable them to undertake marketing campaigns. That is significant and cen tral because the Minister is investing in recruitment and, as everybody knows, this is a world of marketing. Nurse recruitment is no different from other recruitment – it needs investment which has been provided.
The Minister already commented on the improved support for nursing students and I will not repeat it. A new direct entry midwifery education programme will be introduced on a pilot basis next June. This three year programme will be operated by Trinity College in association with the Rotunda Hospital, Dublin, and Our Lady of Lourdes Hospital in Drogheda. A total of 20 training places will be available on the programme which is open to school leavers and mature persons. This takes in all sides – people who are coming through the education system and those who have been through it will have an opportunity. Funding has been provided to maternity hospitals to facilitate a doubling of the theoretical component of the current two year post-registration midwifery education programme from 13 to 26 weeks. Such an increase has been long sought by midwifery interest groups. In this instance the Department and the Minister have responded positively to the profession.
A working group has been established to undertake a review of the content, duration and academic award of the current 18 month post-registration sick children's course or old RSCN course. Again, the Minister and the Department are improving the educational aspects of a discipline and making it more attractive for people to enter.
Although everything is not rosy in the garden, we are making progress, but we cannot be complacent. The opening of the regional schools of psychiatric nursing in St. Brigid's Hospital in Ardee and St. Davnet's Hospital in Monaghan is another step in the right direction. I return to this point again and I do not care who likes it. If local people work in the local hospital, people who came through a local educational nursing facility, there is a fair chance that they will encourage, without saying anything, other young students from the general area, whether in the junior or leaving certificate year. When all the small schools of nursing were closed, a malaise set in. I recall attending an Association of Health Boards conference in 1983 where the then Minister – we will not be political, we will leave him anonymous but we all know who was involved – said that a number of the smaller schools of nursing would have to be closed. They were closed and we are discussing the results here today. That is why we are discussing shortages in nursing in Ireland, why the Minister is here and why Senator Jackman made her contribution.
I welcome the Minister to the House as I always do. As one who is an employee of the Department of Health and Children, I have to be very respectful when the Minister comes to the House. I am very encouraged by the Minister's speech because it is very hard, as Senator Jackman said, to get realistic figures on the current situation in nursing. I accept the figures the Minister has given us and will discuss them presently.
When one looks at nursing overall, the most important thing to accept is that nursing has totally changed in one generation. It used to be a profession into which mainly young women went, apart from the men who entered the psychiatric service, as Senator Glynn said. Young women stayed in this job until they got married and in many cases they could not continue after they got married because of the marriage bar. It is now a totally different profession, where both men and women are considering it as a job for life and are considering their career prospects.
One of the biggest difficulties at the moment is keeping people within the nursing profession because it is such a good training and is extremely versatile. They make extraordinarily useful employees in so many different careers after their training. As Senator Jackman pointed out, we now have to try to do all we can to retain them in the corps of nursing within the hospital service.
The Minister pointed out the increased number of nurses employed in general practices and in the community and all this has led to a drain from the hospitals. We must deal with this terrible problem of keeping people within the hospital service. The Minister pointed out the increased numbers entering nursing and said that the problem is mainly in the Dublin area. When one looks at the figures there are nearly 12,000 staff nurse vacancies, which is horrific for anyone working within the nursing profession. Although the Minister says that with net figure adjustments made up by the utilisation of agency nurses and overtime, this comes down to about 430 vacancies, someone has to work very long hours to make up for those vacancies. This again leads to more people leaving which is one of the unfortunate roll-over effects of any shortage in any department. The work level becomes so great for those who are left that more and more people say they cannot take it any longer and will have to leave. While the employment of agency nurses may be all right on a short-term basis, it is not a satisfactory solution to the shortage of staff nurses. This is where the crux of the problem lies.
One of the disturbing things in the debate on the crisis in nursing over the past year and the dissatisfaction felt by so many nurses with their jobs is that it seems impossible to combine the terms "vocation" and "profession". Vocation only means that one has a calling to do something and nursing is one of the most important jobs for which one should have some aptitude. It is important for patients that one has a desire to go into the profession. When the Minister was in the Department of Education and Science, I am sure he heard the concern expressed that too many people went into medicine because they had the points to do it. This led to a fall off in those who continued to practise medicine afterwards because it was not what they thought it would be. We must ensure that the word "vocation" is given a status in the minds of nurses and they feel it is a worthwhile job.
The profession needs to be properly paid. It was most unfortunate that a strike took place before the financial aspects of the problem were addressed. However, that is over and the issue has been addressed. I presume it will be necessary to pay more to nurses in the Dublin area to encourage them to remain in the profession, but there is no point rehashing the debates held at that time.
The Minister mentioned the Commission on Nursing. The commission was chaired by Miss Justice Mella Carroll and all those who sat on the commission with her spent a tremendous amount of time addressing the problems in the nursing profession and they made good recommendations. The Minister mentioned the issues which have been addressed, including the career structure. This was one of the most important matters but it is most unfortunate that greater kudos still does not appear to be given to expertise in clinical care. The senior staff nurse grade has been introduced, which is important, but clinical care is not given enough status in the nursing profession. More importance is attached to diplomas in intensive care nursing or cardiology than competence in clinical care, which can be more important in terms of the running of the health service.
As a member of the medical profession, one must be able to telephone a nurse and rely on their opinion when one asks about a patient. It is serious if one cannot rely on one's nursing colleagues to have the clinical acumen to be part of the team. However, no status appears to be given to that clinical acumen. It is one of the most important skills because, as Senator Glynn and Senator Jackman said, nurses are there most of the time with patients. One can pick up much more information in the course of bedmaking than a doctor may pick up on rounds once or twice a day.
As I have told the House previously, I remember a case where I and a nursing colleague, the ward sister, could not work out what was wrong with a patient. The sister said that she would go on her own to the woman the following day and make her bed very slowly. She said that by the time she finished making the bed she would have found out what was the problem, and she found out. This type of expertise, tact and consideration for the patient does not appear to be given much consideration. High tech medicine is most important, but the clinical care of patients is at the core of the health service. I do not know what will happen if we do not manage to restore its status.
The career structure has been addressed but I have received complaints from nurses that if they transfer from one hospital to another, even within the same health board, they start at the lower level in the new hospital. This is extraordinary and must be addressed. Perhaps it is part of the Minister's plan with regard to career structures but it is most important.
The involvement of nurses in the management of services is essential. They have always been involved to a certain extent, but their views on how the services should be managed are extraordinarily important. A considerable number of jobs are still done by nurses which could be done by other personnel in the health service. I am not referring to bedmaking. The making of empty beds is one matter, but making beds in which patients are lying is another. The patients could be very ill and one wants the people dealing with them to have expertise. I am not referring to such roles.
Computerisation in the health service has been a splendid development but I work on Monday mornings with a nurse who spends 90% of her time getting results for me. The two of us should be working together, seeing patients, but I work most the time on my own while she is trying to get results from the computer. This is a time consuming job but I cannot expect the hospital to employ a clerk to sit with me. However, the removal of clinical nurses from their jobs to do this type of work is not the best use of their skills.
I welcome the direct entry into midwifery. I am pleased it is associated with the university I represent, Trinity College, Dublin, and the hospital in which I work, the Rotunda. The changes in medical education that are taking place, where people may start off by getting a broader health science qualification, may be important but I note with some alarm the change in the entry requirements for nursing in terms of the removal of the need for a foreign language. Some fluency in a foreign language may not be too important in nursing but I do not favour the downgrading of the nursing requirements.
Hear, hear.
Nursing is a complicated profession and I do not favour the downgrading of mathematics because of the amount of mathematical calculation involved. If one tells a nurse to put a patient on 24,000 units per 24 hours, he or she will have to calculate it from the dosage in a 25ml phial and work out how many drops per minute will be delivered. It is not simple mathematics.
There is no downgrading.
I hope not. I do not understand the reason for the removal of the requirement for a foreign language. That is a university requirement.
If I had my way, I would not have it at university level either.
Neither would I.
It is another day's argument, but there are some great scientists in institutes of technology who could not go to university because they did not have a foreign language. It is a big argument but it does not necessarily represent a downgrading. It is a point of view.
It is a big argument for a country which is about to become multi-cultural.
We are doing that too.
An Leas-Chathaoirleach
Senator Henry is in possession.
I am enjoying the interchanges but I thank the Leas-Chathaoirleach.
This aspect is most important, particularly when nurses from outside the European Union are being recruited. We must be sure that their standards are the same as those in Ireland. Internationally, Ireland's standards are considered to be extraordinarily high and we want to ensure that is maintained.
It is difficult to compare the number of nurses per bed, but the figure in Ireland is 1.26 compared to 0.42 in France. I have found French health care good and perhaps the Minister could explain how these figures are qualified.
I am sorry the Minister did not address the first recommendations of the Commission on Nursing on the regulation of the profession. Has much work been done on this aspect? A considerable number of recommendations were made regarding nurses taking ownership of the regulation of their own profession and the changes needed in the 1985 Act under which An Bord Altranais was established. These changes are major and they were recommended by the commission. They involve a total change in the membership of the board and a recommendation that it would regulate the ethical practices within the profession. The Minister did not mention this area but it is most important.
The report states that the commission recommends the nursing profession take greater responsibility for the regulation and practice of the profession and for ensuring professional leadership in nursing and midwifery. It is bad if this is not being addressed. The report was issued almost three years ago and it is most important that those recommendations are given great emphasis.
Much has been done in an effort to get people to return to the profession. The nurse in my practice comes from Naas. I live in terror that con scription will be introduced for nurses and that she will be seized off the bus in Naas or passing St. James's Hospital and will not get into town. There is a shortage of people at staff nurse grade everywhere in and around Dublin. She is an excellent nurse who trained with me in Sir Patrick Dun's Hospital. There are nurses who have not returned to work but they could be encouraged to do so.
Senator Jackman's suggestion of television advertising was imaginative. It is a good idea and perhaps it would encourage more people to return, even on a part-time basis. The Mater Hospital must be in a state of despair given that it advertised for shifts of two, four, six, eight or 12 hours. It is in the worst situation and it has splendid theatres which are closed. St. Vincent's and Beaumont hospitals face similar problems because of a lack of people for training.
I suggested last night, because of the grave shortage of theatre nurses, that we look at the role theatre technicians play in the United States. I worked in America for a short time and the theatre technicians there were mainly men who had trained in the US army. A great deal of work in theatres is technical work and involves the preparation of instruments and so forth. The grade of theatre technician still exists and the training, as far as I recall, took about two years. I checked this out the other day and it still happens.
We could consider conversion courses because there are science graduates who are not in employment. The Minister and I have encouraged people to take up science and we have expressed our dismay at the drop off in the number of students taking physics and chemistry in the leaving certificate. I am contacted by a considerable number of young graduates from scientific disciplines who are not in employment. With a conversion course some of them may be interested in going into the more technical aspects of nursing. This would help save as many nurses as possible for the really important clinical care areas where no one else can do the job.
This is the real problem. It is not a job which one can replace with other people. Those trained in computers or with a scientific background cannot provide the clinical care which nurses provide, such as mouth care, stomach care and preventing bed sores. Those are the specialised areas for which it is essential to use clinical care nurses. Any means to take the burden off them in other parts of the health service, to allow them concentrate on these important duties, must be promoted. The situation in the Dublin area is difficult, even with the large number of people being trained. Without nurses it is impossible to run the health service in a satisfactory manner.
This is an engaging debate with many interesting insights coming from practitioners in the field, such as Senator Henry. I welcome the newly appointed Minister of State at the Department of Health and Children. This may be her first visit—
I am a regular attender in the Seanad.
That is a reflection on me, not on her. One way or the other the Minister of State is welcome to this debate. Disraeli once said there were three kinds of lies – lies, damn lies and statistics. I have seen many statistics about nurses and their availability in the course of my preparation for this debate. Officially, it would appear on paper that there is a sufficiency of nurses and, perhaps, a surplus. I am informed there are 48,000 qualified registered nurses paid up annually on an active file. In addition, there are 10,000 others who are not paid up annually on an inactive file. That would seem to suggest that we have a sufficiency of nurses. Yet the Mater Hospital's report of 1998 with regard to the intensive care unit refers to a very real decrease in suitably qualified nursing staff in 1998 which led to a reduction in the number of beds available and equally a reduction in the number of elective admissions to that unit. That is a worrying position. The report goes on to say that there is a real difficulty in regard to the shortage and retention of registered nurses within the service, particularly those with appropriate skills in specialised areas. That is reflected in other hospitals.
On the one hand, on paper it appears there is a sufficiency of nurses but, on the other hand, they are not available for work in key areas. This is the dilemma. It is a challenge for the Minister to find out why a large number of nurses, qualified and registered, are not presenting for work. If the problem is to be tackled in an organised fashion it must be established why they are not available for work. What changes could be brought about to ensure their availability, if that is possible? We ought to have a tracking system to see whether it is possible to work out time sharing or work patterns that would make it attractive for them to become active in the service again. I am puzzled, given the number of nurses available on paper, that in overall terms in the Dublin area there is a shortage of about 800 nurses. What is the reason?
We need more scientific information. People speculate that the reason is the high cost of housing in Dublin or the transport difficulty and congestion. That argument could be applied equally to teachers.
That is true.
However, I see no evidence of a surplus of teachers in Clare, Kerry or Galway or a shortage in Dublin. That could apply to any of the professions. That is a speculative explanation for what is happening. The matter needs to be investigated with a view to doing something to confront the problem.
The Mater Hospital's report pinpoints a lack of nurses with certain specialties and in certain areas. That raises the issue of ongoing career development and ongoing nursing education. It is a good time to address the issue given that it has been raised in the report of the Commission on Nursing, the charter for the profession in the future. There are clear guidelines in that report which, if implemented, should provide a sufficiency of ongoing career development education to enable us to have the nurses we need and in the specialties where they appear to be lacking at present.
The message I give to the Minister this morning is that the recommendations of the Commission on Nursing should be implemented fully and with the minimum of delay. That is the most professional way to approach the problem of insufficient supply in specialist nursing areas.
Senator Henry has drawn attention to the need to maintain the entry requirements for nursing training. Nursing now calls for high levels of capability, intelligence and skill. If nurses are to progress in their careers we must insist that the high standard which has given Irish nurses the professional status they enjoy and deserve is maintained. There must be no lowering of standards.
There is no shortage of young people applying for nursing training. There were 5,000 applicants for the 1,500 training places which were filled this month, three applicants for every available place. While there is no difficulty in persuading bright young people to enter the nursing profession, the challenge is to keep them in the profession and to keep them in Ireland when their training is complete. We must offer young nurses career paths which are challenging, innovative and interesting to keep them at home.
We must train more nurses. Our ageing population will demand a high quality of life and standard of health care and this will lead to a demand for more nursing care of the sort which can be delivered in sub-acute hospitals, nursing homes and by public health nurses in patients' homes. During last evening's discussion on hospital waiting lists, I raised the need to find ways of keeping people out of hospital. The only way to do this is by providing sufficient nursing care in the community. This is the most compassionate and caring way to deliver health care to older people. I grew up in a time when a stigma attached to being put into the county home. This came from the time of the famine when people would have died on a ditch rather than go into the county home. Folk memories die hard and old people like to be among their old, familiar things. We will serve our senior citizens well if we can keep them in their homes for as long as possible and provide home helps, carers and public health nurses in an integrated service. We can only advance this aim if we have a sufficiency of nurses. As our population ages and we assess people's needs for acute hospital and other forms of medical care, we will need many more nurses. We must train more nurses to meet the demands of community health care as well as the needs of our hospitals.
I am pleased by the Minister's proposal to upgrade midwifery education. The Minister for Health and Children and the Minister of State both have a background in education. During his time as Minister for Education and Science, Deputy Martin paid much attention to the need to give young children a good start in schools. The Christian Brothers used to say that if they were given a lad for the first seven years of his life they would make a man of him. Although that motto may be crudely expressed, it contains much sound philosophy. What happens in the early years determines the course of a person's life and influences the way he deals with personal relationships and with the many situations he will meet in the course of his life.
However, a person's future can be influenced even sooner. A midwife can play an enormous role in giving a young person the right start in life. It is a frightening experience for a young woman to be faced with a small baby without the advice and support of a midwife. Midwives teach young mothers how to bond with their children and by so doing start infants on a healthy course in life. The critically important role of widwives has not been given sufficient attention. Midwives are not given the recognition which they merit. Their role in the health service needs to be upgraded. I applaud the Minister for introducing, on a pilot basis, direct entry into midwifery education through Trinity College. This is a real advance. I hope this will be a pilot scheme only for as long as is absolutely necessary to establish patterns which can be put in place elsewhere and become the norm. I welcome the Minister's pledge to double the theoretical component of the current two-year post-registration midwifery education programme from 13 to 26 weeks. This is also a major step in the right direction and I applaud the Minister for taking it.
The nursing profession faces a challenging time. Nurses have found a freedom to do other things and to work elsewhere which is not available to other professionals. Nursing is the most mobile of all forms of professional training. If one can nurse in Ballybunion one can nurse in Bahrain. We must seek to upgrade nursing education and ensure the objectives in the commission's report are met fully and within the minimum time. This carries an in-built risk. People can be educated and they may have aspirations and ambitions which might be exercised elsewhere, but not necessarily in our hospitals. We must be acutely aware that having a sufficient number of entrants to the profession, a good developmental approach to career building and career education, we must provide the necessary conditions in our hospitals and communities for nurses to remain to give their service.
I welcome the Minister of State, Deputy Hanafin, and wish her well in her new portfolio.
I have listened attentively to my colleagues and some fine contributions have been made to the extent that my thinking is bogged down. I came in with a clear mind as to what I wanted to say, but I am not so sure now. However, I will speak on my feeling towards the nursing profession. I listened to and read the Minister's speech, and I note the key points relate to the nursing shortage. I asked myself why there should be a nursing shortage and it brought to mind the controversy of the nurses' dispute last October. Wearing another hat, I spoke to my colleagues as to where the nursing profession is going wrong and what is going wrong. The nub of the problem is that the jury is still out on whether there should be an academic or a hands on approach. Many people feel there is a divide between those who have done diploma courses recently and those who have gone through the hands on system. An inferiority complex is building up between the two areas, hence the problems in people getting allowances for their academic qualifications versus those with a hands on approach. This problem has existed for a long time in the teaching profession and it is now creeping into the nursing profession – I am among teachers who understand what I am saying.
I am not convinced we should take the academic route immediately. Perhaps it is wrong that in order for people in the medical profession to access the CAO they need a point rating of almost 600 points. After ten years in general practice, one will find that many GPs are disillusioned, disenchanted and no longer want that particular lifestyle because they are not stretched. They are doing work which would be more suited, perhaps, to care workers rather than the nursing or medical profession. The nursing profession may go the same way. Is nursing a vocation or has it become a prestigious profession where people must have academic qualifications before they can gain hands on experience? It would be better if the reverse were the case and I would like to see that happening. I would like to say to students if they are interested in nursing, if they are dedicated and committed to a nursing way of life then perhaps they should spend two or three years working in a hospital to get a real feel of communicating with patients and be in a position to understand and interact with hospital life. Following that, they should move into the academic sphere of the culture of nursing.
The Minister has set up a National Council for the Professional Development of Nursing and Midwifery to examine the transition from the diploma course to the four year degree course. I read the document carefully and I am not convinced we are going about this in the right way. We must consider this matter in terms of the time it takes people to get their academic achievements versus general suitability. Can the council tackle this problem before it comes up with its findings? I have concerns in that regard. Before the final recommendations are made many consultations will have to take place between nurse tutors, the broad section of those involved in the health care area, teachers and, to give a plug to my previous profession, guidance counsellors who will have a big role to play in the vocation orientation of those aged between 16 and 17 who may be interested and may have a totally different approach to what they want from the nursing profession. There is the reality.
I am coming down strongly on the role of public health nurses. I will make no bones about the fact that my mother won the gold medal in Ireland and England in her final nursing examination and continued her role as a public health nurse throughout her life. I have much knowledge on how public health nurses behaved in the past and how they behave today. I was nominated to the Cultural and Educational Panel of the Seanad by the Institute of Community Health Nurses. Therefore, I have a second interest in promoting the role of public health nurses in the few minutes remaining to me.
There are approximately 1,350 public health nurses. The service needs a skill mix of public health nurses, registered general nurses, home care attendants and home help to meet the needs of the community. Until the 1980s, approximately 70 public health nurses were trained each year. When the course moved to diploma level, UCD accepted only 30 people. Despite UCC offering a further 20 places there is still an acute shortage of public health nurses. In the Eastern Regional Health Authority area alone there are 30 public health nurse vacancies. There should be 1:3,000 public health nurses to population, but what is this population? Many public health nurses are carrying case loads of 1:6,000 or more. The complement of public health nurses has not increased despite the expansion of population, the changing social needs and increase in the workload.
Let us examine the role of public health nurses. They offer a service to clients from birth to death and support and advice to parents following child birth until the child is of school going age. Mothers and infants are being discharged early from hospital, in some instances within 24 hours of delivery. This has implications for the service as many infants require metabolic screening within 48 hours. Mothers also require regular visits initially to help them establish breast feeding. Research shows that most women who stop breast feeding early do so within the first week due to lack of support. The increase in the number of different ethnic groups also puts increasing pressure on the service. Public health nurses continue to work closely and develop links with marginal groups and have successfully recruited Travellers and refugees who now work as community mothers. This helps deliver a client friendly service to some extent. Public health nurses frequently require interpreters to help them communicate with different groups.
Regarding the delivery of pre-school and school health and screening services, more input from public health nurses is required at an early stage. Under a measure known as the hospital initiative, people are being discharged from hospitals early. Many of these people require a nursing service. Ambiguity arises in the area of medical card holder versus non-medical card holder. Who supplies the dressings for non-medical card clients? These people would get this service free of charge if they were in hospital or if they returned to hospital. This area needs to be addressed urgently if we are to provide seamless care, a new phrase which means a co-ordinated approach.
With regard to providing a range of nursing services to the elderly and support for carers in the home, the Eastern Health Board's district care team was established to enable people over 65 years of age to be discharged early, thereby making hospital beds available. A structured multi-disciplinary team was employed. This measure has proven to be cost-effective and beneficial in enabling older people to stay at home. People were admitted to the district care unit for a 12 week period and many of them continued to live at home afterwards with basic intervention.
Carers need more support to enable them to care in the long term. Day care and step down facilities need to be developed urgently, ideally in primary care premises. Clients in nursing homes receive a subvention of approximately £175 per week. Over 75% of the Eastern Health Board's clients receive that sum. If some of this money was allocated to the community more people could be cared for at home.
The public health nurse is required to have a register of people over 65 years of age. Unless the public health nurse receives a referral he or she may not be aware of these people. In order to plan services it is essential that all public health nurses carry out an area profile to determine the real needs of an area.
Another role of the health service is to provide nursing services and support in the home for persons with a disability. Many people with varying degrees of disability are living at home and require care of some kind. Unfortunately, the public health nurse service is often unable to supply a quality service to this client group due to a lack of resources.
Public health nurses are actively involved in the delivery of structured health promotion programmes, such as post-natal classes, breast feeding support, smoking cessation classes, cervical screening, blood pressure clinics and continence clinics. This is all done on an ad hoc basis as clinical work takes priority. In order to give a quality service more public health nurses are required.
The hospital liaison service needs to be developed as private hospitals are not visited. It is important that all people, regardless of age or means, are referred to this service. All people requiring a nursing service should be referred to the public health nurse service, regardless of income. The Commission on Nursing recommends that the Department of Health and Children issue a revised strategy statement on the role of public health nursing. The Institute of Community Health Nurses, the public health nurses' professional body, welcomes this initiative. The institute will carry out research into the public health nursing service to determine its needs and demands and to identify the different standards provided throughout the country. It will also conduct a consumer review of the service. The institute believes the service should be co-ordinated and transparent.
As clients are being discharged early from hospitals it is imperative that resources are allocated to the community services in order that we have a quality, seamless service. I gave a lot of thought to my contribution and got ideas from my background, my guidance counselling role and from public health nurses. I ask the Minister to pay attention to the public health nurses because they are the core of our society. If we do not have them, the back-up support and the care staff that is necessary to facilitate the profession, then we are not at the races in terms of the nursing profession. I also ask him to examine the academic versus the hands-on approach. I am not convinced we are going about it the right way.
I know the Minister will be good at his job and I have confidence in him. He grasped the education portfolio very well and I have no doubt that he will do likewise with his current portfolio. I wish him well. This is a serious area and I hope he will come into the Seanad again.
I welcome the Minister and wish him well in his new responsibilities.
I rise to restore the gender balance to this debate and to help with another perspective. I am chairman of a hospital in Belfast. I spent some of my professional life preparing manpower estimates and forecasts for health service employees, particularly nurses. Invariably my forecasts turned out to be wrong. It is a very difficult area and I am glad the Minister can avail of the report by the Commission on Nursing. It is a solid and thoughtful document and I commend Miss Justice Mella Carroll and her colleagues who prepared it. The Minister should use it as the basis for forward progress.
Nursing problems are not confined to this jurisdiction; we have them also in Northern Ireland. I hope the Minister will be encouraged to think that there could be a constructive cross-Border exchange of views on this area. It does not have to wait for structures. The profession North and South should get together.
In the North and South we have underestimated the impact of changes in nurse training arrangements and the withdrawal of all of those staff from the wards. Some Senators have asked what will happen when the newly trained nurses return to the wards. The nursing profession is the bedrock of any health service. It is a resource that should be cherished. While I do not want to enter into the debate on money, I do not think it is all about money. We should think about the working conditions, status, promotion and resources. As Senator Jackman said, a great part of the problem is that nurses are in the front line. Nurses must deal with the patients and their families when they are in a distressed state. They will be better off the more that role is alleviated.
As Senator Ormonde said, it is worthwhile to look at the broader picture and not to focus all the time on the hospitals. People can be prevented from going into hospital. If there had been people on hand during the 'flu epidemic to give old people advice, particularly on how to prevent dehydration, many of them would not have had to go into hospital. If there had been step down facilities in the community hospital beds could have been freed up. It is a wide picture at which I encourage the Minister to look laterally, as I know he will.
Nursing is a vocation. The trouble is that when we talk about vocations we seem to invite people to offer themselves up as sacrifices. The true vocationalism one finds in most nurses should not be exploited. Senator Jackman referred to what sounded to me as a very interesting survey in Cork of the reasons people enter nursing. Thought should also be applied to the reasons they leave it. The drain from nursing is just as important.
It is my experience that during the years there has probably been a greater loss of trained personnel from nursing than from any other profession, thereby giving a lower return on the money invested in training. There is, therefore, in the community a reservoir of people who have the required vocation and received basic training. The hospital with which I am concerned is encouraging such people to return by organising back to nursing days to let them see what nursing is like today. We have had some success with fairly trendy advertising campaigns.
We should ask ourselves why nurses prefer to work for agencies. I have no wish to denigrate the agencies concerned but if those are the conditions which attract nurses to work why can they not be replicated within the health service? They cover such matters as hours of work and provide for flexibility to give nurses the opportunity to do other things. There is much work to be done in that field.
I encourage the Minister not to look at the profession as a single shop. It is a very complex and mixed profession. Increasingly medicine is becoming specialised. The Minister will have to look therefore at the possibility of providing for specialisation in the case of psychiatric, community and paediatric nursing for instance. Difficulties are being experienced in recruiting nurses into the highly specialised ends of the profession and retaining them. This presents a great problem. They are extremely highly qualified, they are working under enormous pressure and they have to be helped and sustained. Medicine has become a team operation, of which nurses are a hugely important part with the various medical practitioners and ancillaries. A means has to be found of retaining nurses as part of intensive care, neurosurgery, cardiology and paediatric nursing teams.
I am glad there has been reference to maintaining the connection with clinical practice. During the years nursing shared with teaching and social work a great disadvantage. To progress in their careers nurses had to stop doing what they were good at and start doing things at which they were not always good and for which they did not have a taste. There is a real argument to be made for introducing career grade nursing. I am not aware of all the details but there is a move to introduce a consultant nurse in the United Kingdom. Something like that, which would keep highly experienced, dedicated and motivated nurses working at what they are good at, would be worth the investment.
It is also important that there is a move back to the schools and education. There is a hitherto undiscovered nugget in the Patten report which relates mainly to policing. It contains a suggestion that some inner city schools should develop a stream to encourage young people to think of employment in the social and public services such as nursing, social work and policing. It may be that that is the level at which one has to start.
Like Senator Ormonde, I have reservations about the over-intellectualisation of entry to medicine in particular. The academic high fliers want to do trendy and sexy things, such as heart transplants and neurosurgery, whereas we want them to look after mentally handicapped kids and babies. There is, therefore, a mismatch in terms of measuring a person's caring potential. This is something the professions should think about. Do we really want highly trained nurses to be making beds? The work of others such as ancillaries and domestics who are a hugely important part of the caring team should be enriched. We may well have to think of introducing what used to be called a State enrolled nurse to do this work.
I invite the Minister to think of nursing as a profession in transition in a changing world and health universe and to maintain flexibility. I wish him well and strongly commend the concerns of my fellow Senators and, in particular, the report of the Commission on Nursing.
I welcome the Minister and congratulate him on his new appointment. From what he said today and his record as Minister for Education and Science I am certain there will be many changes and much good work done in the health service, particularly on the subject under discussion. I agree with the sentiments expressed by most other speakers on the service provided by nurses. As Senator Hayes said, they expend much time doing mundane work such as making beds when they could be doing other work. They do substantial work on behalf of hospital consultants. We all realise how badly off we would be without them.
I wish to raise an issue that has been placed on the agenda in the last week in the North Western Health Board. It was kept very quiet for many years but was due to hit the fan on 1 April. It relates to the ambulance service and ambulance nurses in particular. There is one large general hospital in County Donegal, located in Letterkenny, which is situated 50 to 60 miles from areas which are not even served by a district hospital. The ambulance service and ambulance nurses in particular are vitally important to such communities.
Following a review of the national ambulance service a national agreement was entered into 1993 under which, by 1 April next, all ambulances are to be staffed by emergency medical technicians who need not necessarily include the driver who may possibly have paramedical skills. The second person on the ambulance need not necessarily be a nurse. This is a source of great fear in County Donegal where ambulances are staffed by a driver who has received certain medical training and a nurse. It takes up to half an hour for an ambulance to reach someone's door in Glencolumbcille and a further hour and half on some of the worst roads in the country – on which the Minister has travelled – to reach Letterkenny General Hospital. Therefore, it is vital that there is a carer in the ambulance who can deal with the patient being transported. I accept that the review could possibly be considered in large cities and even in a town in the vicinity of Letterkenny, for example, where it might only take ten or 15 minutes to get to the hospital, but it is different in outlying areas such as Glencolmcille or parts of the Gweedore Peninsula, where the ambulance service at Dungloe can take, perhaps, 15 minutes to get the ambulance on the road, a further half an hour to get to the scene at Knockfola, for example, which is at the most northerly point, and then a further hour and a bit to get to Letterkenny.
I have nothing against the ambulance drivers. They do excellent work. Indeed, in accident situations an ambulance driver might be even more beneficial to a patient due to his physique and strength than a nurse, but my worry is that when the patient is in the ambulance and on the way to hospital, he or she is not in the care of a nurse.
I understand that there has been an intervention by the nurses' trade union in the past couple of days which may stall this new arrangement due to the fact that they are probably fighting for conditions and pay terms. I plead with the Minister on behalf of people living in out-of-the-way areas, like Glencolmcille, from where it takes hours to get to the hospital. Patients need a nurse in the ambulance. Even with up to date training which some of the ambulance EMTs have undergone, many patients would rely on having a nurse. I find it difficult to understand how a person who spends maybe 16 weeks training and has 26 weeks' experience in the service can be more qualified than a nurse who has done three years' training. A nurse is trained to deal with clinical situations and my concern is about such cases.
I am not here to represent the nurses as the trade unions can represent them. I am here to represent the public of south-west Donegal, which is one of the areas which will suffer most due to the number of nurses staffing ambulances there and the distance between outlying areas and the hospital.
I ask the Minister to look into the matter to see if anything can be done. I know the nurses have the option to be upgraded to EMTs by doing the advanced training course, but some of them will not be allowed to go back into the hospital service. I am plead for the making of an exception, particularly in the west, so that a nurse can be retained on ambulances rather than having two EMTs.
Is the Minister not going to reply?
It is not normal for the Minister to reply to statements. He can communicate with you personally.
Sitting suspended at 1.04 p.m. and resumed at 2 p.m.